Labor Management: Original Research
Second Stage of Labor and Epidural Use
A Larger Effect Than Previously Suggested
Yvonne W. Cheng, MD, PhD, Brian L. Shaffer, MD,
and Aaron B. Caughey, MD, PhD
OBJECTIVE: To examine the length of second stage of
labor with and without an epidural during labor.
METHODS: This was a retrospective cohort study of
42,268 women who delivered vaginally with normal
neonatal outcomes. Median lengths and 95th percentiles
of second stage of labor were compared by epidural
use with stratification by parity. Statistical comparisons
were performed using the Kruskal-Wallis test and
Kaplan-Meier survival analysis.
RESULTS: Compared with women without epidural use,
the 95th percentile length of second stage for nulliparous
women was 197 minutes without epidural and 336 mi-
nutes with epidural (P,.001), a difference of 2 hours and
19 minutes. For multiparous women, the 95th percentile
length of second stage was 81 minutes without epidural
and 255 minutes with epidural (P,.001), a difference of
2 hours and 54 minutes.
CONCLUSION: Although recommendations for inter-
vention during the second stage of labor have been
made based on a 1-hour difference in the setting of
epidural use, it appears that the 95th percentile duration
is actually more than 2 hours longer with epidural during
labor for both nulliparous and multiparous women.
(Obstet Gynecol 2014;123:527–35)
DOI: 10.1097/AOG.0000000000000134
LEVEL OF EVIDENCE: II
From the Division of Maternal-Fetal Medicine, Department of Obstetrics,
Gynecology and Reproductive Sciences, University of California, San Francisco,
California; the Department of Obstetrics and Gynecology, Oregon Health &
Science University, Portland, Oregon; and the Department of Family Medicine,
Penn State Hershey Medical Center, Hershey, Pennsylvania.
Presented as an oral presentation at the Society for Maternal-Fetal Medicine
Annual meeting, February 7–12, 2011, San Francisco, California.
Corresponding author: Yvonne W. Cheng, MD, PhD, Division of Maternal-
Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences,
University of California, San Francisco, 505 Parnassus Avenue Box 0132, San
Francisco, CA 94143; e-mail: chengy@obgyn.ucsf.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2014 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/14
VOL. 123, NO. 3, MARCH 2014
James M. Nicholson, MD, MSCE,
T oday, nearly one in three pregnant women under-
goes cesarean delivery in the United States.1 With
vaginal birth after cesarean delivery rates nationally
at less than 10%,1 delivery by cesarean nearly assures
that all subsequent births will likewise be by this
route. Minimizing primary cesarean delivery is a
priority.2 Two common indications of cesarean
during labor are active phase arrest and arrest of
descent.3,4 Current labor norms were established by
Dr. Emmanuel Friedman in the 1950s5,6 with the orig-
inal intent of presenting average length of labor.5,6
Recently, Zhang et al suggested that the pro-
gression of labor in modern obstetrics may deviate
from that established by Friedman.7,8 Changes in
obstetric practice over time included a much higher
prevalence of epidural analgesia and oxytocin aug-
mentation during labor and a substantially lower rate
of forceps and vacuum-assisted vaginal deliveries.9
The American College of Obstetricians and Gynecol-
ogists (the College) Practice Bulletin on labor dystocia
states the mean durations of second stage of labor in
nulliparous and multiparous women are 54 and 19 mi-
nutes, respectively.10,11 It defined prolonged second
stage of labor as more than 2 hours without epidural
or 3 hours with epidural in nulliparous women, and 1
hour without or 2 hours with epidural for multiparous
women.10 The basis of these parameters is unclear,
and the additional hour allotted for labor with epidu-
ral anesthesia appears to be based on the mean effect
of epidural.10–12
The median length of labor is frequently reported
in describing normal labor progression and 95th
percentile thresholds are commonly utilized to define
the extreme ends of a distribution. Thus, our research
aim was to describe the median and the 95th
percentile lengths of second stage of labor based on
parity and epidural use. We hypothesized that epidu-
ral anesthesia would have been associated with an
increase of more than 1 hour at the 95th percentile
thresholds during the second stage of labor.
OBSTETRICS & GYNECOLOGY 527
MATERIALS AND METHODS
We designed a retrospective cohort study of all
cephalic, live, singleton births to women who deliv-
ered at the University of California, San Francisco
between 1976 and 2008. The Committee on Human
Research at University of California, San Francisco
approved the study. The exclusion criteria were no
labor, multifetal gestations, noncephalic presentation,
placenta previa, intrauterine fetal demise, or known
lethal congenital anomalies. We also excluded women
who delivered during the first stage of labor by
cesarean and therefore would have had a second stage
of labor length of 0 minutes. Additionally, we
excluded women with missing or incomplete infor-
mation about the duration of second stage of labor.
There were 53,682 singleton births that were deliv-
ered during the study period and 48,474 (90.3%) had
labor. Of these, 1,225 women (2.5%) had missing
information about length of second stage of labor. All
deliveries at this academic institution were performed
by the attending physicians, clinical nurse midwives,
or resident physicians with supervision of either an
attending physician or a clinical nurse midwife. The
number of deliveries remained stable during the study
period, ranging between 1,400 and 1,800 deliveries
per year. Of the women who met study inclusion or
exclusion criteria who delivered by cesarean, approx-
imately 60% of those cesarean deliveries were per-
formed for arrest of descent, another 12% were
performed for fetal intolerance of labor, and 11%
were performed for failed forceps or vacuum-assisted
vaginal delivery.
The maternal characteristics and labor informa-
tion were prospectively collected by the managing
physicians of the labor and delivery unit. Neonatal
information was similarly collected by neonatologists
and pediatricians using a neonatal database. The
maternal and neonatal databases were then linked
using two unique identifiers and cross-checked for
complete linkage. Additionally, trained abstractors
performed daily chart review and data abstraction to
ensure information accuracy and to minimize missing
data. The database also underwent monthly review by
trained physicians for quality assurance. The database
was created in 1976, and detailed perinatal and labor
information continued to be prospectively collected
and maintained during the entire study period and is
ongoing. The length of second stage of labor was
defined as time interval between complete cervical
dilation to delivery of the fetus.
The primary outcomes were the median and the
95th percentile lengths of second stage of labor. We
528 Cheng et al Epidural and Length of Second Stage of Labor
chose to examine the median and the 95th percentile
thresholds because the length of second stage of labor
in the study population was not of normal distribu-
tion. Length of labor in women with labor epidural
was compared with length of labor in women without
epidural, stratified by parity. Statistical analysis was
performed using Kruskal-Wallis and x2 tests. Survival
analysis was also used to examine the length of second
stage of labor. We also performed subgroup analysis.
We stratified by mode of delivery, induction and aug-
mentation of labor, and time period of delivery
(1976–1989, 1990–1999, and 2000–2008). Addition-
ally, we examined the length of second stage of labor
based on neonatal outcomes. We created a composite
variable, “neonatal morbidity,” which included those
neonates with Apgar score less than 7 at 5 minutes,
umbilical artery cord gas pH level less than 7.0, neo-
natal sepsis, meconium aspiration syndrome, admis-
sions to the neonatal intensive care unit, and birth
trauma (cephalohematoma, head laceration, clavicu-
lar fracture, skull fracture, facial nerve palsy, and
Erb [or brachial plexus] palsy).
The secondary outcomes included maternal and
neonatal outcomes. These included mode of delivery,
peripartum infection, postpartum hemorrhage, and
severe perineal lacerations for maternal outcomes.
Neonatal outcomes examined were 5-minute Apgar
score less than 7, umbilical cord artery pH level less
than 7.0, meconium aspiration syndrome, neonatal
sepsis, intensive care unit admission, and birth trauma.
The association between length of labor and perinatal
outcomes was examined using x2 test and multivariable
logistic regression analysis. A full logistic regression
model was built, and subsequent stepwise backward
elimination with P,.20 as the cut-off was performed
to derive a parsimonious regression model. The only
covariate that had a P..20 was maternal insurance sta-
tus. However, we opted to keep insurance status in the
final regression model because it was associated with
epidural use and maternal and neonatal outcomes.
Thus, covariates included in the multivariable logistic
regressions were maternal age older than 35 years, race
or ethnicity, marital status, public insurance, gestational
age at delivery, epidural use, induction of labor, and
delivery year. Of note, we had intended to include
oxytocin augmentation of labor as a covariate in the
logistic regression model; however, it was omitted in
the regression analyses because of collinearity with
induction of labor. We also included mode of delivery
and birth weight in the regression models for neonatal
outcomes. Statistical analysis was performed using
STATA 11.0. Statistical significance was indicated
using P,.05 and 95% confidence intervals.
OBSTETRICS & GYNECOLOGY
RESULTS
There were 42,268 women who met study criteria
with normal neonatal outcomes. Among them, 49.9%
(n521,090) had epidural during labor and 50.1%
(n521,178) did not. In our cohort, epidural use varied
by parity, maternal age, and race or ethnicity (P,.001
for all; Table 1). Women who had induction of labor
or oxytocin augmentation were also more likely to
have epidural analgesia in labor (P,.001 for both;
Table 1). The proportion of women who had epidural
anesthesia during labor increased during the study
period (P,.001; Table 1).
For nulliparous women, the median length of
second stage of labor was 47 minutes without epidural
and 120 minutes in the presence of epidural use,
a prolongation of an additional 73 minutes (P,.001).
When we examined the length of labor in nulliparous
women with and without epidural at the 95th percen-
tile threshold, it was 197 minutes with epidural and
336 minutes without epidural. The difference of the
95th percentile thresholds between nulliparous
women with and without epidural was 139 minutes,
or 2 hours and 19 minutes (P,.001; Table 2). This
95th percentile threshold difference in duration of sec-
ond stage of labor was larger than that of the median
values. This relationship between second stage of
labor duration and epidural was further explored
using Kaplan-Meier survival analysis in which the
95th percentile differences in labor duration of
women without and with epidural were longer than
that of median differences (Fig. 1). For multiparous
women, the median lengths were 14 minutes without
epidural and 38 minutes with epidural, a prolongation
of 24 minutes (P,.001; Table 2). However, at the 95th
percentile thresholds, they were 81 minutes without
and 225 minutes with epidural, a difference of 2 hours
and 54 minutes.
We further performed subgroup analysis. There
were 35,681 women (subcohort) who had vaginal
delivery without neonatal morbidity. Among them,
nulliparous women without epidural had a median
and 95th percentile second stage of labor length of
47 minutes and 190 minutes, respectively. For nullip-
arous women with epidural, the median and 95th
percentile second stage of labor lengths were 112 mi-
nutes and 302 minutes, respectively (Table 2).
Although the difference in median length between
nulliparous women with and without epidural was
65 minutes, the difference in 95th percentile length
was 112 minutes. Similarly, for multiparous women
who delivered vaginally with normal neonatal out-
comes, the median and 95th percentile second stage
of labor length were 14 minutes and 79 minutes with-
out epidural, and 38 minutes and 217 minutes with

Table 1. Maternal and Labor Characteristics Among Women Who Received Epidural During Labor and
Those Who Did Not

Characteristic No Epidural (n521,178) Epidural in Labor (n521,090) P

Parity
Nulliparous (n522,370) 40.3 59.7 ,.001
Multiparous (n519,855) 61.1 38.9
Maternal age (y)
Older than 35 (n535,411) 51.0 49.0 ,.001
Younger than 35 (n56,829) 45.5 54.5
Race or ethnicity
Caucasian (16,894) 46.4 53.6
African American (n54,979) 47.3 52.7 ,.001
Latina (n54,444) 49.4 50.6
Asian (n56,611) 53.3 46.7
Other or unknown (9,108) 56.7 43.3
Labor induction
Induction (n56,012) 32.5 67.5 ,.001
No induction (n536,177) 53.0 47.0
Labor augmentation
Augmentation (n511,153) 24.2 75.8 ,.001
No augmentation (n525,294) 65.4 34.6
Delivery year
1976–1989 (n517,339) 64.7 35.3
1990–1999 (n513,703) 45.4 54.6 ,.001
2000–2008 (n511,226) 33.3 66.7
Data are % unless otherwise specified.

VOL. 123, NO. 3, MARCH 2014 Cheng et al Epidural and Length of Second Stage of Labor 529
Table 2. Length of Second Stage of Labor Among the Entire Study Cohort and Subgroups

Vaginal Delivery
Entire Cohort Without Neonatal Spontaneous Vaginal Operative Vaginal
(N542,225) Morbidity* (n535,681) Delivery (n533,239) Delivery (n56,851)
95th 95th 95th 95th
n Median Percentile n Median Percentile n Median Percentile n Median Percentile
Nulliparous, no 9,026 45 197 7,962 47 190 7,882 43 167 1,029 82 276
epidural
Nulliparous, 13,344 120 336 10,371 112 302 7,754 88 261 4,135 170 336
epidural
Multiparous, no 12,124 14 81 10,988 14 79 11,518 13 75 431 31 200
epidural
Multiparous, 7,731 38 255 6,360 38 217 6,085 31 177 1,256 80 295
epidural
Data are minutes unless otherwise specified.
* Neonatal morbidity defined as Apgar score less than 7 at 5 minutes, umbilical artery cord gas pH level less than 7.0, neonatal sepsis,
meconium aspiration syndrome, admissions to the neonatal intensive care unit, and birth trauma (cephalohematoma, head laceration,
clavicular fracture, skull fracture, facial nerve palsy, and Erb [or brachial plexus] palsy).
†
P,.001 for all comparisons between epidural and no epidural.

epidural (P,.001; Table 2). The difference in the 95th
percentile length between multiparous women with
and without epidural was 138 minutes. Similar trends
of longer median and 95th percentile thresholds with
epidural compared with without epidural were seen for
women who had spontaneous vaginal deliver (P,.001;
Table 2). Among women who had operative vaginal
delivery (n56,851) by either forceps or vacuum-
assisted vaginal delivery, the median and 95th percen-
tile lengths of second stage of labor were longer in those
with epidural than those without (P,.001; Table 2).
We also examined length of second stage of labor
among women who had induction of labor (n56,004)
and those who did not (n536,150), and among
women who had oxytocin augmentation of labor
(n511,402) and those without augmentation of labor
(n525,270). Again, the median and 95th percentile
lengths of second stage of labor were longer with epidu-
ral than without for both nulliparous and multiparous
women with and without induction (P,.001;
Table 3). Although the length of second stage of
labor was statistically significantly different by parity
and epidural status among women who were induced
compared with those who were not induced (P,.001
for all), these thresholds did not appear to be clini-
cally significantly different (Table 3). Similar trends
were augmentation of labor (Table 3). However, we did
not have information regarding indication of oxytocin
augmentation in this dataset to further explore this
association.
We explored the relationship between epidural
anesthesia and length of second stage of labor
stratified by parity and year of delivery. The median
length of second stage of labor remained relatively
similar across each of the study periods (1976–1988,
1989–1999, 2000–2008; Table 4). Among multipa-
rous women without and with epidural, similar trends
were also seen for the median length of second stage

100

75
Pregnant (%)

Median differences

50
Epidural
No epidural
25
95th centile differences Fig. 1. Kaplan-Meier survival analy-
P<.001 by log-rank sis of second stage of labor duration
0 in nulliparous women with and
0 2 4 6 6 10 without an epidural during labor.
Cheng. Epidural and Length of Second
Second stage of labor (hours) Stage of Labor. Obstet Gynecol 2014.

530 Cheng et al Epidural and Length of Second Stage of Labor OBSTETRICS & GYNECOLOGY
Table 3. Median and 95th Percentile Length of Second Stage of Labor Stratified by Induction of Labor and
Augmentation of Labor

No Induction of Induction of No Augmentation of Augmentation of

Labor (n536,150) Labor (n56,004) Labor (n525,270) Labor (n511,042)
95th 95th 95th 95th
N Median Percentile n Median Percentile n Median Percentile n Median Percentile
Nulliparous, no 8,178 46 196 832 43 212 6,794 45 180 1,416 55 262
epidural
Nulliparous, 10,802 121 338 2,519 111 327 4,998 106 311 5,824 135 358
epidural
Multiparous, no 10,987 14 81 1,118 13 80 9,738 13 76 1,281 14 135
epidural
Multiparous, 6,183 40 261 1,535 31 233 3,740 39 245 2,521 40 289
epidural
Data are minutes unless otherwise specified.
* P,.001 for all comparisons between epidural and no epidural.

of labor. Although statistical significance (P,.001) was
reached for these comparisons, the median lengths
likely were of little clinical significance (Table 4). In
contrast, the 95th percentile thresholds of second
stage of labor were progressively longer across the
time periods. For nulliparous women without and
with epidural, the 95th percentile thresholds were
163 minutes and 270 minutes, respectively, during
delivery years 1976 to 1989. The 95th percentile
thresholds were 199 minutes and 325 minutes for nul-
liparous women without and with epidural, respec-
tively, during 1990 to 1999. They were 347 minutes
and 432 minutes, respectively, during 2000 to 2008
(P,.001; Table 4). A similar increase in 95th percen-
tile thresholds of second stage of labor was seen for
multiparous women without and with epidural and
across study periods (P,.001; Table 4).
We then explored the definition for abnormal or
prolonged second stage of labor. In this study cohort,
using the current definition of prolonged second stage
of labor defined by the College,10 16.2% of nullipa-
rous women without epidural and 31.1% of nullipa-
rous women with epidural in labor would be
considered as having prolonged second stage of labor;
the proportion for multiparous women was 7.7% with-
out and 18.9% with epidural (Table 5). Because the
95th percentile thresholds of second stage of labor for
this cohort was longer than the current definition, we
examined the proportion of women who would have
prolonged second stage of labor diagnosed if 1 addi-
tional hour were allotted to current thresholds (ie, 3
hours without epidural or 4 hours with epidural in
nulliparous women, and 2 hours without or 3 hours
with epidural for multiparous women). Using this cri-
teria, 6.6% of nulliparous women without epidural
and 16.2% with epidural would have prolonged sec-
ond stage of labor diagnosed; similarly, 3.0% of mul-
tiparous without and 10.4% with epidural would have
prolonged second stage of labor diagnosed (Table 5).
Another strategy to define prolonged second stage
of labor is to use the 95th percentile thresholds. In
doing so, approximately 5% of the population would
have prolonged second stage diagnosed, with the thresh-
olds of more than 197 minutes for nulliparous
women without epidural, 336 minutes for nullipa-
rous women with epidural, 81 minutes for multipa-
rous women without epidural, and 255 minutes with
epidural (Table 5).

Table 4. Median and 95th Percentile Thresholds of Second Stage of Labor With Stratification by Study
Period

1976–1989 (n517,339) 1990–1999 (n513,703) 2000–2008 (n511,226)

Median 95th Percentile Median 95th Percentile Median 95th Percentile

Nulliparous, no epidural 45 163 41 199 60 347

Nulliparous, epidural 112 270 118 325 130 432
Multiparous, no epidural 14 67 12 77 16 178
Multiparous, epidural 42 203 37 270 36 312
Data are number of minutes.
* P,.001 for all comparisons between epidural and no epidural, and across stratified study periods.

VOL. 123, NO. 3, MARCH 2014 Cheng et al Epidural and Length of Second Stage of Labor 531
Table 5. Proportion of Women Diagnosed With Prolonged Second Stage of Labor

College Definition Cohort Defined Using 95th

College Definition Plus 1 Additional h Percentile Threshold*
Threshold % Diagnosed Threshold % Diagnosed Threshold % Diagnosed

Nulliparous, no epidural .120 16.2 More than 180 6.6 More than 197 5
Nulliparous, epidural .180 31.1 More than 240 16.2 More than 336 5
Multiparous, no epidural .60 7.7 More than 120 3.0 More than 81 5
Multiparous, epidural .120 18.9 More than 180 10.4 More than 255 5
College, American College of Obstetricians and Gynecologists.
Data are minutes unless otherwise specified.
* Derived from 5% of study population with the longest second stage of labor.

We examined whether prolonged second stage of
labor would be associated with undesirable neonatal
outcomes by using definitions currently established by
the College,10 College thresholds plus 1 additional
hour, and the 95th percentile thresholds according
to the study cohort. Based on the College’s defini-
tion,10 18.9% of women would have prolonged second
stage of labor diagnosed. Compared with women
without prolonged second stage of labor, there were
no statistically significant differences in the incidence
or odds of neonatal outcomes except for birth trauma
(adjusted odds ratio 1.58; 95% confidence interval
1.13–2.22; Table 6). When we defined prolonged sec-
ond stage of labor using the current College definition
plus 1 additional hour, 9.3% (n53,923) of women
would be considered to have a prolonged second

Table 6. Neonatal Outcomes Associated With Prolonged Second Stage of Labor

No Prolonged Prolonged Adjusted OR*

Second Stage (%) Second Stage (%) (95% CI)

College definition
n 34,263 8,005
5-min Apgar score less than 7 3.51 3.16 1.16 (0.96–1.41)
Umbilical cord arterial pH level less than 7.0 0.52 0.82 1.39 (0.88–2.20)
Meconium aspiration syndrome 0.56 0.85 0.95 (0.65–1.38)
Sepsis 0.53 0.35 0.87 (0.47–1.32)
Intensive care nursery admission 9.23 7.76 1.22 (0.95–1.29)
Birth trauma† 0.49 1.01 1.58 (1.13–2.22)
College definition plus 1 additional h
n 38,345 3,923
5-min Apgar score less than 7 3.45 3.43 1.12 (0.87–1.45)
Umbilical cord arterial pH level less than 7.0 0.55 0.85 1.31 (0.75–2.26)
Meconium aspiration syndrome 0.58 0.99 1.10 (0.68–1.77)
Sepsis 0.51 0.36 0.77 (0.40–1.49)
Intensive care nursery admission 8.97 8.77 1.03 (0.84–1.25)
Birth trauma† 0.52 1.24 2.08 (1.38–3.15)
95th percentile thresholds
n 32,141 1,580
5-min Apgar score less than 7 3.43 3.40 1.25 (0.86–1.81)
Umbilical cord arterial pH level less than 7.0 0.56 0.87 1.58 (0.73–3.44)
Meconium aspiration syndrome 0.61 0.76 0.98 (0.47–2.08)
Sepsis 0.18 0.51 0.56 (0.17–1.81)
Intensive care nursery admission 8.89 7.90 0.90 (0.66–1.23)
Birth trauma† 0.54 1.60 2.73 (1.62–4.61)
College, American College of Obstetricians and Gynecologists; OR, odds ratio; CI, confidence interval.
Data are % unless otherwise specified.
* Multivariable logistic regression model adjusting for: maternal age greater than 35 years, race or ethnicity, marital status, public insurance,
gestational age at delivery, epidural use, induction of labor, delivery year, mode of delivery, and birth weight.
†
Birth trauma is a composite variable of cephalohematoma, head laceration, clavicular fracture, skull fracture, facial nerve palsy, and Erb
(or brachial plexus) palsy.

532 Cheng et al Epidural and Length of Second Stage of Labor OBSTETRICS & GYNECOLOGY
stage of labor (Table 6). Using this threshold, there
were no differences in neonatal outcome except for
birth trauma (adjusted odds ratio, 2.08; 95% confi-
dence interval, 1.38–3.15) among prolonged second
stage of labor compared with those without (Table 6).
When we defined prolonged second stage of labor
using the 95th percentile thresholds based on the
study cohort (Tables 1 and 5), 4.7% (n51,580) would
be considered to have a prolonged second stage of
labor. Using this definition, again there were no differ-
ences in neonatal outcome except for birth trauma
(adjusted odds ratio, 2.73; 95% confidence interval,
1.62–4.61) among women with prolonged second
stage of labor compared with their counterparts
(Table 6). We also examined maternal outcomes asso-
ciated with prolonged second stage of labor using
these three proposed criteria (Table7). Compared
with women without prolonged second stage of labor,
women whose second stage of labor durations were
considered prolonged had eight-times to nine-times
the odds of cesarean delivery and two-times to
three-times the odds of operative vaginal delivery
(Table7). The odds of third-degree or fourth-degree
perineal lacerations, postpartum hemorrhage, cho-
rioamnionitis, and endomyometritis were similarly
higher in women with a prolonged second stage of
labor than those without (Table 3). This was the case
for all three proposed criteria for prolonged second
stage of labor.
DISCUSSION
We observed that the length of second stage of labor
in women with epidural was longer than for women
without epidural analgesia. Although the majority of
obstetrician–gynecologists subscribe to the clinical
guidelines of giving 1 additional hour to account for
epidural use, it appears that the differences from epi-
dural at the 95th percentiles may be approximately
double.10 Thus, the current definition of prolonged
second stage of labor may be too stringent.
When we examined the length of second stage of
labor in women who achieved vaginal delivery
without adverse neonatal outcomes, those with an
epidural continued to have a second stage of labor
duration of more than 1 hour longer compared with
women without an epidural. Additionally, the 95th

Table 7. Maternal Outcomes Associated With Prolonged Second Stage of Labor

No Prolonged Prolonged Adjusted OR*

Second Stage Second Stage (95% CI)

College definition
n 34,263 8,005
Cesarean delivery 11.5 36.5 9.75 (8.59–11.1)
Operative vaginal delivery 11.5 36.5 2.93 (2.66–3.22)
Third-degree or fourth degree perineal laceration 6.8 16.3 1.96 (1.75–2.21)
Postpartum hemorrhage 6.1 15.2 2.19 (1.94–2.47)
Chorioamnionitis 4.4 13.0 2.16 (1.93–2.41)
Endomyometritis 1.1 3.7 3.17 (2.57–3.92)
College definition plus 1 additional h
n 38,345 3,923
Cesarean delivery 8.27 (7.28–9.39)
Operative vaginal delivery 14.0 37.5 3.57 (3.32–3.85)
Third-degree or fourth-degree perineal laceration 7.8 17.2 2.14 (1.95–2.34)
Postpartum hemorrhage 6.9 16.9 2.37 (2.15–2.61)
Chorioamnionitis 5.1 15.2 1.98 (1.93–2.41)
Endomyometritis 1.3 4.3 3.13 (2.59–3.77)
95th percentile thresholds
n 32,141 1,580
Cesarean delivery 3.6 21.3 9.37 (7.98–11.0)
Operative vaginal delivery 16.6 30.6 2.92 (2.57–3.33)
Third-degree or fourth degree perineal laceration 9.2 15.2 1.94 (1.66–2.27)
Postpartum hemorrhage 7.6 17.2 2.47 (2.12–2.86)
Chorioamnionitis 5.3 11.0 1.95 (1.52–2.35)
Endomyometritis 1.7 4.4 3.53 (2.69–4.63)
College, American College of Obstetricians and Gynecologists; OR, odds ratio; CI, confidence interval.
Data are % unless otherwise specified.
* Multivariable logistic regression model adjusting for: maternal age older than 35 years, race or ethnicity, marital status, public insurance,
gestational age at delivery, epidural use, induction of labor, delivery year, mode of delivery, and birth weight.

VOL. 123, NO. 3, MARCH 2014 Cheng et al Epidural and Length of Second Stage of Labor 533
percentile thresholds in women with an epidural who
had spontaneous vaginal delivery without neonatal
morbidity in this study were similar to those reported
by Zhang et al13 in a multicenter study (the Consor-
tium on Safe Labor). Despite differences in study
design and population, it seemed reassuring that sim-
ilar second stage of labor characteristics were indepen-
dently observed for women who achieved vaginal
delivery.
Using the current definitions of prolonged second
stage of labor defined by the College,10 approximately
31% of nulliparous and 19% of multiparous women
with epidural anesthesia in the study cohort would be
identified as having a prolonged second stage of labor.
Although the passage of time is not an indication for
operative intervention,10 women receiving an epidural
during labor remained at higher risk for operative
vaginal delivery.14 Although most interventions likely
were clinically indicated, it remains possible that some
were performed primarily for the diagnosis of abnor-
mal second stage, particularly when 20% to 30% of
laboring women who received an epidural would
meet such definitions. Thus, we advocate that the def-
inition of prolonged second stage of labor should be
reexamined.
Interestingly, in a recent joint workshop on how to
reduce the first cesarean delivery by the Eunice Kennedy
Shriver National Institute of Child Health and Develop-
ment, the Society for Maternal-Fetal Medicine, and the
College, the group proposed thresholds of 3 hours
without epidural and 4 hours with epidural during
labor for nulliparous women and 2 hours without and
3 hours with epidural for multiparous women.2 Our
data also support longer thresholds for nulliparous
women without epidural. Concordant with recent
data,7,14,15 we also observed that the length of labor
became progressive longer over time. Although the
precise reasons for this remained unclear, changing
obstetric characteristics, such as higher proportion of
induced or augmented labor, fewer forceps and high-
station operative deliveries, as well as increased preva-
lence of obesity and gestational weight gain might play
a role.1,7,9 During the study period, immediate pushing
during the second stage of labor was usually the prac-
tice model and delayed pushing was not widely insti-
tuted. Thus, the probability of delayed pushing as
a contributor to increased length of second stage of
labor over time, although possible, was likely low.
Interestingly, when we examined whether birth weight
increased during the study period, it remained rela-
tively the same. Thus, we could not consider birth
weight as a potential factor for progressively increasing
length of second stage of labor during the study period.
534 Cheng et al Epidural and Length of Second Stage of Labor
We were able to explore length of second stage of
labor in relation to epidural use and associated
perinatal outcomes in various clinical scenarios.
However, there were limitations. First, missing data
or inaccurate information could potentially bias our
findings. It was reassuring that only 2.5% of potential
study participants had missing information regarding
length of second stage of labor. Second, the study
period was long. This, however, enabled the exami-
nation of labor pattern over time. Additionally, we
analyzed data from one academic institution, which
could potentially limit the generalizability of study
findings to the broader population. Although labor
management at the study hospital may vary from that
of other institutions, our study findings were similar to
those reported by a large, multicentered study of labor
pattern.13
In summary, the use of epidural anesthesia during
labor lengthened the median and the 95th percentile
thresholds of second stage of labor. The 95th percen-
tile thresholds of second stage of labor were more
than 2 hours longer in women with epidural com-
pared with those without epidural during labor for
both nulliparous and multiparous women. To put
these findings in context, using current prolonged
labor definitions, one would label nearly one-third of
nulliparous women with epidural as having abnormal
labor. This likely leads to potentially unnecessary
interventions. Although labor norms should not be
established based on this study alone, our findings,
along with those of others, suggest that current
definitions of prolonged second stage of labor in the
setting of an otherwise reassuring fetal status may be
insufficient. There exists a need to establish proper
second stage of labor norms to reflect modern
obstetrics.
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Harold A. Kaminetzky Award

The American College of Obstetricians and Gynecologists (the College) and Obstetrics & Gynecology
have established the Harold A. Kaminetzky Award to recognize the best paper from a non-U.S.
researcher each year.

Dr. Harold A. Kaminetzky, former College Secretary and President, as well as Vice President,
Practice Activities, has had a long career as editor of major medical journals. His last editorship
was as Editor of the International Journal of Gynecology and Obstetrics. Dr. Kaminetzky has also had a
long interest in international activities.

The Harold A. Kaminetzky Award winner will be chosen by the editors and a special committee
of former Editorial Board members. The recipient of the award will receive $2,000.
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